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Conceptual Shift for Palliative Care Life Prolonging Care Life Prolonging Care Medicare Hospice Benefit Hospice Care Palliative Care Dx Not this But this Death 2 Hospice • Eligibility restricted by prognosis/willingness to give up disease Rx • 46% of all U.S. deaths served (2014) • Median length of service: 17 days • At home: 60% • Over age 65: 84% • Outcomes: better QOL, lower cost https://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Fig Doubling in Number of Hospices 2000 - 2015 4500 3,925 4000 4,092 4,199 2014 2015 3,250 3500 3000 2500 2,255 2000 1500 1000 500 0 2000 2007 2013 Number of Hospices Source: MedPAC March 2017 Report to Congress Geographic Variation in Access: % of Medicare Decedents Receiving Hospice – CY2014 21-39% 40-49% 50-59% > 60% Source: CMS Hospice PUF Files, October 2016 for patients who received at least 1 day of hospice care in CY2014 Click on a state to change color Hospital Palliative Care Growth in the U.S. ►In 2015, hospital programs were serving over 8MM patients each year. ►Palliative care prevalence and # of patients served has more than tripled since 2000. ► 100% of the U.S. News 2014 – 2015 Honor Roll Hospitals Have a Palliative Care Team. ► 100% of the U.S. News 2014 – 2015 Honor Roll Children’s Hospitals Have Palliative Care Teams. Palliative Care is Present at: 100% Of the top 20 NIH-funded medical schools 97% of the Council of Teaching Hospitals member organizations 87% of the National Cancer Institute’s 87% designated comprehensive cancer centers Geographic Variation in Hospital Palliative Care https://reportcard.capc.org/ http://online.liebertpub.com/toc/jpm/0/0 Palliative Care Improves Value Quality improves – Symptoms – Quality of life – Length of life – Family satisfaction – Family bereavement outcomes – MD satisfaction Costs reduced – Hospital cost/day – Use of hospital, ICU, ED – 30 day readmissions – Hospitality mortality – Labs, imaging, pharmaceuticals Mr. B • 2015: An 88 year old man with dementia admitted via the ED for management of back pain due to spinal stenosis and arthritis. • Pain is 8/10 on admission, for which he is taking 5 gm of acetaminophen/day. • Admitted 3 times in 2 months for pain (2x), falls, and altered mental status due to constipation. • His family (83 year old wife) is overwhelmed. Mr. B: • Mr. B: “Don’t take me to the hospital! Please!” • Mrs. B: “He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do.” Modified from and with thanks to Dave Casarett Before and After Usual Care Palliative Care at Home • 4 calls to 911 in a 3 month period, leading to • 4 ED visits and • 3 hospitalizations, leading to • Hospital acquired infection • Functional decline • Family distress • • • • • • • Housecalls referral Pain management 24/7 phone coverage Support for caregiver Meals on Wheels Friendly visitor program No 911 calls, ED visits, or hospitalizations in last 2 years Access to Palliative Care in Community Settings How do we get from here to there? • Today’s sessions will demonstrate a number of serious illness models shifting care for patients like Mr. B. out of EDs and hospitals and into homes and community. • Listen for the common characteristics. • Think about policy and delivery system changes necessary to make the community based care and social service supports you will hear about today into the standard of care for people with serious illness.